51176 (3)LOT NO. 02 IIS -
APP=
S
NO. STREET
APCP�LGON 14TjFOR PLUMBING PERMIT
® 1 nil
CUPERTINO
Sanitary No.
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Date •%� .Permit Nos -//71r.
Pee $ 9 S`--"
ApplicAV-5�R� eby alp if of Cupertino for a permit to install plumbing
pipes andyorlfi'xtuhrsrlis n Tt: side hereof, and agrees to install said prices
and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
Cupertino, and all other laws applicable thereto.
Use of Premises 1�1Krl•
Owner
nyll%`
ONTRACTOR,AGENT
Phone G�•`� ,�� e
State License
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Address2/'SJ7
Address 3J^�'7'"'l
ApproveNILL1AM D. BENEVICH
PLUMBING INSPECTOR
FIXTURES
NUMBER
MAIN DRAIN
UNITS FEES
UNITS FEES
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen Sink
Not Conn.
Dish Washer
Sewer Box
Waste Disposal
Wash Tray
STORM DRAINAGE
Washing Machine
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit
Drinking Fountain
Floor Drain
WATER SYS'T'EM
Hopper
Size
Restaurant Sink
Material
Sand Trap
TOTAL FEI'S
Urinal
Fixture Fee (�
Area Drain
I Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler Valve
Water Sys. Fee
Relief Valve
/ ,
Gas Fee
Vac Breaker
/
Skimmer
Filter
/
Permit Fee
Total
°i
Total Fee